Neck Pain: Diagnosis And Management

Neck Pain: Diagnosis And Management

This is a long article from Practical Pain Management that gives a full explanation of the neck itself, along with the cause, diagnosis, and treatment of neck pain. I’ve annotated and organized it, hoping this makes it easier to read and understand.

Anatomic Cervical Spine – Functional Anatomy

The cervical spine consists of seven cervical vertebra and eight cervical nerve roots.

The C1-C2 (atlantoaxial) joint forms the upper cervical segment, which allows for 50% of all cervical rotation. The occipitoatlantal joint is responsible for 50% of flexion and extension.  

Below the C2-C3 level, lateral bending of the cervical spine is coupled with rotation in the same direction. This is due to the 45° inclination of the cervical facet joints.

The vertebral bodies of C3-C7 are similar in appearance and function (Figures 1 and 2). They articulate via the zygapophyseal or facet joints posteriorly.

neck-vertebra1

neck-vertebra2

On the lateral aspect of the vertebral bodies are sharply defined margins, which articulate with the facet above. These articulations are called uncovertebral joints, or the joints of Luschka.

These joints can develop osteophytic spurs, which can narrow the intervertebral foramina. Intervertebral discs are located between the vertebral bodies of C2-C7.

The discs are composed of an outer annular fibrosis and an inner nucleus pulposus and serve as force dissipators, transmitting compressive loads throughout a range of motion.

The intervertebral discs are thicker anteriorly and therefore contribute to normal cervical lordosis.

The foramina are largest at C2-C3 and progressively decrease in size to the C6-C7 level. The nerve root occupies 25% to 33% of the foraminal space.

The nerve roots exit above their correspondingly numbered vertebral body from C2-C7; C1 exits between the occiput and atlas, and C8 exits below the C7 vertebral body.

Degenerative changes of the structures that form the foramina can cause nerve root compression. This compression can occur from osteophyte formation, disc herniation, or a combination of the two.

History and Physical Examination

Notable Components of History

  • Mechanism of injury
  • Location and intensity of the pain
  • Aggravating and relieving factors
  • Neurologic symptoms
  • History of prior neck injury or complaints

Notable Components of Physical Exam

  • Inspection
  • Palpation
  • Range of motion
  • Neuromuscular examination
  • Provocative tests

Red Flags

Table 2 highlights common red flags to be aware of. These should prompt clinicians to screen for ominous diagnoses.

neck-red flag

Differential Diagnoses

Table 3 covers a wide range of diagnoses and suggests a corresponding management plan.

neck-diag

neck-cervical

Diagnostic Tests

Imaging Studies

Neck pain associated with red flags or that persists beyond 6 weeks may benefit from radiographic evaluation.

The Canadian Cervical Spine Rule (Table 4) is a helpful algorithm to further assess the need for imaging of neck pain after trauma.

Routine imaging studies of nonspecific neck pain—such as plain x-rays and MRI—have a significant number of false positive findings, which often do not correlate with the patient’s symptoms and are therefore not indicated.

  • Plain radiograph: Plain radiograph or x-ray is often the first imaging modality following an initial evaluation.
  • MRI, computed tomography (CT) myelogram, and CT scan: Patients with neurologic signs/symptoms should proceed with MRI without contrast to assess for possible causes such as cervical disc herniation, cervical stenosis, and to rule out serious causes such as a spinal tumor and infection.
  • CT with myelogram is the alternative imaging choice for individuals with contraindications for MRI

Electrodiagnostic Studies

Electrodiagnosis allows for physiologic evaluation of the nervous system. As an extension of physical examination, it can achieve the following purposes:

  • detect nerve pathology,
  • localize level(s) of involvement,
  • estimate timing of nerve injury,
  • prognosticate outcome, and
  • demonstrate electrodiagnostic evidence of recovery.

Useful studies include:

  • Nerve conduction studies to rule out peripheral neuropathy
  • Electromyography (EMG) is the most sensitive study to assess for nerve root involvement, and has greatest yield 3 weeks after onset of symptoms
  • Motor- and somatosensory-evoked potentials assess for spinal stenosis, and may detect subclinical upper motor neuron signs

Rehabilitation Concepts

A rehabilitative program can begin once serious etiologies of neck pain are ruled out

The guiding principle in neck pain rehabilitation is to encourage early mobilization and rapid return to normal activity level. With a handful of exceptions, the scientific evidence for common treatments of neck pain is poorly validated. Systematic reviews do however support multimodal treatments over any single modality.

Phases of Rehabilitation

Regardless of modality choice, there are three phases in neck pain rehabilitation.

  1. The first is the acute phase, where pain control is the primary goal.
  2. Next comes the restorative phase, which focuses on recovering range of motion, correcting biomechanical deficits, and strengthening.
  3. Then, the patient transitions to a home exercise program and advance activity as tolerated in the final maintenance phase.

If progress is not made, the diagnosis should be reassessed and the treatment modified as necessary.

Conservative Management Options

Education and Relative Rest

Reassure patients that neck pain is a common problem and often resolves on its own within a few weeks. Avoiding painful positions for a few days before returning to a normal activity level is a reasonable option, but do stress the importance of early mobilization.

Pharmacotherapy

While no studies have fully validated the efficacy of any medications in the management of neck pain, patients with significant pain may benefit from pharmacotherapy to allow for quick return to normal activities

Medication choice depends on individual profiles, and the options include:

  • Non-steroidal anti-inflammatory drugs (NSAIDs): The combined analgesic and anti-inflammatory properties make them common first-line agents
  • Acetaminophen: Counsel on conservative daily intake in patients with alcohol abuse, advanced age, and concomitant anticonvulsant use
  • Topical analgesic agents: Topical menthol, capsaicin, and camphor are widely available over the counter.
  • Muscle relaxants: The limited use of skeletal muscle relaxants may be considered in cases of muscle spasm and pain
  • Steroids: A short taper is often prescribed for acute radicular pain and has been reported to be beneficia
  • Anticonvulsants and tricyclic antidepressants: Both classes of medication have been used adjunctively to reduce chronic neck and radicular pain.  There are no studies to support their use in acute neck pain
  • Opioids: Opioids, such as tramadol and oxycodone, may be tried if other medications fail to provide adequate relief or are contraindicated

Manipulation and Mobilization

Mobilization includes all non-thrust manual therapies (eg, muscle energy and strain–counterstrain techniques) designed to overcome restricted joints and lengthen shortened muscles.

There is evidence showing that both modalities provide at least short-term benefit in patients with neck pain and are thus viable options.

Exercise Therapy and Physical Therapy

There is further evidence supporting the clinical efficacy of exercise combined with cervical mobilization/manipulation in acute and chronic neck pain

The general exercise regimen may include:

  • Stretching: Regular, prolonged stretching helps overcome soft tissue shortening and tightening that most commonly affect the anterior cervical and thoracic musculature
  • Strengthening and endurance: Progressive strengthening helps compensate for the relative weakness that most commonly plagues the posterior cervical, shoulder girdle, and scapular/thoracic musculature
  • Coordination: Proprioceptive training maximizes recovery and aims to prevent recurrence of neck pain

Physical therapy provides a structured, supervised program that guides patients to return to full activity.

In addition to stretching and strengthening, the therapy prescription may include the following:

  • Passive mobilization: The use of manipulation and myofascial release can be helpful initially to release the noncontractile elements of soft tissues
  • Mechanical traction: Intermittent, mechanical traction can be trialed for possible improvement of radicular symptoms
  • Stabilization: This aspect of therapy deals with posture re-education, optimizing dynamic positions, and incorporating patterned movements to achieve complex, functional tasks
  • Home program: Exercises that will help maintain strength and flexibility will be identified and incorporated into a regular home program

Acupuncture and Low Level Laser Therapy

Acupuncture has moderate evidence supporting short-term clinical benefits in neck pain present greater than 3 months

There are also currently a handful of randomized controlled trials suggesting good short-term clinical efficacy of low level laser therapy (LLLT) in patients with acute and chronic neck pain. LLLT uses a single-wavelength laser to reduce inflammation and possibly alter cellular function

Other Treatment Modalities

  • Massage
  • biofeedback
  • acupressure
  • ultrasonography
  • electrotherapy (eg
  • transcutaneous electrical nerve stimulation
  • electrical muscle stimulation
  • and pulsed electromagnetic therapy)
  • diathermy
  • ethyl chloride spray and stretch
  • cervical traction
  • dry needling
  • trigger-point injections

are examples of various treatment modalities that are commonly used to treat neck pain. The clinical efficacy of these therapies is not supported by the current literature.

Aggressive Management Options

Patients suffering from severe, chronic disability despite conservative management may consider more aggressive management options, such as:

  • Epidural corticosteroid injection: This procedure aims to reduce inflammation at the targeted spine level. It is used to treat neck pain due to cervical degenerative disc and facet disease.
  • Medial branch block: Medial branch block is a diagnostic—and on occasion, therapeutic—procedure that numbs the nerves supplying the targeted facet joint(s). There is good evidence that it can provide long-term and short-term relief
  • Radiofrequency neurotomy: Radiofrequency denervates targeted medial branch nerve(s). If patients are confirmed to have facet-based pain by medial branch block, neurotomy can be pursued for long-term pain relief.66 Expected pain relief is between 9 months and 1 year
  • Pulsed radiofrequency treatment: Pulses of currents can be delivered via an implanted electrode at a targeted level to modulate pain. In recent studies, it appears to have significant short- and long-term effectiveness for patients with chronic refractory cervical pain.
  • Surgery is best indicated in patients with radiculopathy with clearly identified pathology—for example, single-level disc herniation that corrlelates with the findings on history and physical examination. Procedures include laminectomy, discectomy, corpectomy, and fusion.

Conclusions

The goals of treatment are pain reduction and return of daily function.

This should include a discharge to an independent home exercise and self-management program, which avoids an overreliance on passive treatments and repeated visiting to healthcare clinicians. In the author’s experience this approach is successful in the vast majority of patients treated.

2 thoughts on “Neck Pain: Diagnosis And Management

  1. Pingback: DIY Help for Cervicogenic Headaches | EDS and Chronic Pain News & Info

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